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HEALTH CARE POLICY
Largest International Mental Health Survey Finds Widespread Illness, Checkered TreatmentThose who claim that mental health is the Cinderella of the health care system may feel justified by the latest report from the WHO World Mental Health Consortium. Writing in the June 2 Journal of the American Medical Association, the consortium reveals that worldwide, the challenge of treating those most severely affected by mental disorders is largely unmet.
A WHO study led by Ronald Kessler has found that worldwide mental health receives short shrift. As many as 85 percent of those with severe mental illness go untreated. (Photo by Graham Ramsay) In the largest study of its kind ever undertaken, the consortium surveyed more than 60,000 adults from 14 countries across Europe, the Americas, Africa, Asia, and the Middle East. Interviewees were asked to assess if, during the previous 12 months, they experienced or received treatment for a variety of mental disorders, including anxiety disorders (such as post-traumatic stress disorder and obsessive-compulsive disorders), mood disorders (such as bipolar disorders and depressions), impulse control disorders (such as bulimia) and substance abuse disorders. "The level of impairment we found to be associated with serious mental disorders was staggering," said Ronald Kessler, HMS professor of health care policy and principal investigator of the consortium. The report found that between 1 and 4 percent of the population in most countries met the criteria for a serious mental disorder, and these patients reported being unable to carry out their normal daily activities for more than a month during the past year. "There are very few physical illnesses that have impairments as great as these," Kessler said. The consortium also found that the proportion of mentally ill people who receive treatment is woefully inadequate throughout the world. This was even true of those with the most severe illnesses. Between 35 and 85 percent of these respondents received no treatment during the previous year, even though they were so debilitated that they lost the ability to function for between 30 and 80 days over the same time period. In the United States, about 48 percent of those with serious mental illness received no treatment. In less developed countries, percentages were higher.
But the consortium recognizes that shifting the balance of treatment to those who need it most may be easier said than done. "The practical complexities of reallocating resources are many and varied," commented Kessler. In the United States, for example, with its decentralized health system, it is not readily apparent how one could divert resources from middle class patients with mild disorders to poorer patients with more serious illnesses. In other countries reallocation may be easier. A recent study by Kessler and colleagues showed that in Ontario, where the ability to pay is less of a constraint than in the United States, a higher proportion of patients with serious mental illness are treated, while in the United States, a higher proportion of mild cases are treated. But is reallocation alone the answer? "There is no guarantee that reallocating resources away from mild cases would solve the problem of unmet need for treatment among serious cases," said Kessler. This is true for a variety of reasons. Serious cases often require more intensive treatment, so resources for 10 mild cases may be needed to help one patient with a serious disorder. In addition, treating mild cases can sometimes be more cost-effective, particularly if it prevents progression to a more severe disorder. "Wholesale reallocation of resources is not an answer," Kessler suggested. "Instead, we need more careful consideration of long-term cost-effectiveness of alternative treatment methods and treatment targets." The World Mental Health survey is ongoing in a total of 28 countries and when completed will have questioned nearly a quarter of a million people. --Tom Fagan |
